Does Medicare Cover Hospice Care?

Does Medicare cover hospice? Absolutely. For those facing a terminal diagnosis with a life expectancy of 6 months or less, Medicare Part A steps in to provide hospice care. In this article, we’ll succinctly explain the scope of this coverage, including who qualifies, what’s included, and any associated costs, so you can make informed decisions during this challenging time.

 

Key Takeaways

  • Medicare covers hospice care under Part A for terminally ill patients, prioritizing comfort over curative treatment, with coverage that can be extended indefinitely in six-month periods subject to ongoing eligibility.

 

  • The Medicare hospice benefit includes comprehensive services for pain management, symptom control, medical equipment, and counseling, although beneficiaries may incur some costs such as 5% coinsurance for drugs and copayments for outpatient drugs and inpatient respite care.

 

  • Hospice care under Medicare has no time limit; it provides initial coverage for two 90-day periods followed by unlimited 60-day extensions, with certain services excluded, such as room and board, curative treatments, and services by non-hospice providers.

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Medicare's Hospice Coverage

Medicare does indeed cover hospice care under its Part A, making medicare cover hospice care for terminally ill patients with a life expectancy of six months or less, who choose comfort care over curative treatment. The hospice program is designed to prioritize the patient’s comfort, focusing on pain management and symptom control rather than curative interventions.

This approach is beneficial for patients like Mary, who may prefer to focus on quality of life in her remaining months.

Patients must obtain certification of their terminal illness from a hospice doctor and their personal physician to qualify for the hospice benefit. They must also sign a statement electing hospice care over other Medicare benefits for treating their terminal illness and related conditions. Medicare’s hospice coverage can be extended indefinitely in six-month increments, as long as the patient continues to meet the eligibility criteria.

 

Medicare's Hospice Coverage

Services Included in Medicare’s Hospice Benefit

The Medicare hospice benefit includes a wide range of services designed to enhance patient comfort and support their families. These services fall into three main categories: pain management and symptom control, medical equipment and supplies, and counseling and support services.

We will now examine each of these areas in detail.

 

Pain Management and Symptom Control

Pain management and symptom control form the cornerstone of hospice care. The goal is to enhance patient comfort, alleviating pain and other distressing symptoms associated with the terminal illness.

The hospice care team collaborates to develop a personalized plan that addresses the patient’s specific needs, which may include medication management, non-pharmacological interventions, and emotional and psychological support.

Medicare covers the cost of medications required for symptom management in hospice care. There is no cost for hospice care, and Medicare’s hospice benefit should include coverage for any prescription drugs required for pain and symptom management related to the terminal condition. The attending medical professional will work with the hospice team to determine the appropriate medications for each patient.

Also, specific non-pharmacological options for pain management in hospice care are covered by Medicare.

 

Medical Equipment and Supplies

In addition to pain management, Medicare’s hospice benefit encompasses coverage for medical equipment and supplies necessary for alleviating pain and managing symptoms. This includes:

 

  • Durable medical equipment
  • Bandages
  • Wound dressings
  • Catheters

 

The hospice care team, which may include a nurse practitioner, will determine the appropriate equipment and supplies for each patient.

 

Does medicare part b cover hospice

 

 

Patients do, however, have some financial responsibilities. There is a 5% coinsurance requirement for drugs or biologicals covered by Medicare. Additionally, patients may be responsible for a copayment for outpatient drugs used for pain and symptom management.

Furthermore, Medicare provides coverage for specific durable medical equipment after it has paid 80% of the approved amount. Medical equipment and supplies can be replaced or updated as needed under Medicare’s hospice coverage, to maintain continuous pain relief and symptom management for the patient.

 

Counseling and Support Services

Emotional and psychological support, alongside physical care and symptom management, play a vital role in hospice care. Medicare’s hospice benefit includes counseling and support services that are accessible to both patients and their families.

These services encompass aspects such as spiritual and grief counseling to aid them during the hospice care period.

Grief counseling is especially important, as it provides mental health services to those struggling with the impending loss of their loved one. Patients and families can access counseling and support services by meeting the eligibility criteria for Medicare Part A and choosing hospice care. This counseling can extend for a maximum of one year after the patient’s death, with sessions scheduled as necessary.

Levels of Hospice Care and Payment Rates

There are four levels of hospice care that Medicare covers:

 

  1. routine home care,
  2. continuous home care,
  3. general inpatient care,
  4. and respite care.

 

These levels are determined based on the patient’s needs and condition. Medicare determines the daily payment rate for hospice services based on one of these four categories: routine home care (RHC), continuous home care (CHC), inpatient respite care (IRC), and general inpatient care (GIP).

 

How long will medicare pay for hospice care

 

 

Factors that influence the levels of hospice care and the corresponding payment rates include:

 

  • The minority composition of the county
  • The level of care provided
  • The type of care needed
  • The location of care
  • The length of care
  • Local differences in area wage levels

 

Furthermore, these payment rates are subject to annual adjustments.

For example, there was a 3.8% increase in payments in FY 2023 compared to FY 2022, and in FY 2024, there was a 3.1% increase in payments compared to FY 2023.

Coinsurance and Out-of-Pocket Costs

While Medicare covers a comprehensive range of hospice services, some coinsurance and out-of-pocket costs may apply. The term coinsurance denotes the share of the healthcare expenses that the patient is accountable for covering after deductibles have been fulfilled.

For instance, the individual may be required to pay a copayment of up to $5 for each prescription drug for pain and symptoms, and a coinsurance amount of 5% for inpatient respite care as part of Medicare’s hospice benefit.

However, it’s worth noting that there is a limitation on the number of days of inpatient respite care for which Medicare will provide payment, set at 20 percent of a hospice’s total Medicare patient care days. It’s essential for patients and their families to understand these potential costs and plan accordingly.

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Hospice Quality Reporting Program

The Hospice Quality Reporting Program (HQRP) forms a significant part of Medicare’s hospice coverage. It’s designed to gather data from hospices using the Hospice Item Set (HIS) data collection tool and Medicare hospice claims.

This collected data is used to assess performance on quality measures. The objective of the HQRP within Medicare’s hospice coverage is to assess the hospice organization’s capacity to meet patient needs and care outcomes during their hospice stay.

The quality standards of the HQRP are formulated in accordance with the stipulations outlined in Section 3004(a) of the Patient Protection and Affordable Care Act (ACA) of 2010. All Medicare-certified hospice providers are obligated to adhere to the reporting requirements of the Hospice Quality Reporting Program (HQRP).

The program currently operates under a ‘pay-for-reporting’ model, necessitating providers to report specific quality measures. This data is utilized to evaluate the quality of care offered by hospices and is publicly disclosed, potentially influencing the organization’s reputation and its capacity to attract and retain staff.

 

Medicare Advantage Plans and Hospice Care

Though Medicare Advantage plans offer supplementary health coverage, they do not extend to hospice care. Once hospice care commences, Original Medicare covers the services associated with the terminal illness.

If you’re enrolled in a Medicare Advantage Plan and seeking to initiate hospice care, it’s necessary to request assistance from your plan in locating a Medicare-approved hospice provider within your vicinity.

The expenses related to hospice care within a Medicare Advantage plan can vary based on the particular plan and its regulations concerning such care. Once the hospice benefit is initiated, Original Medicare will cover all necessary expenses related to terminal illness. This includes medical care and support services to manage symptoms and provide emotional and spiritual support.

Duration of Medicare Hospice Coverage

An important advantage of Medicare’s hospice coverage is its lack of a specific time limit. Medicare allows a patient to receive hospice care for an initial duration of up to two 90-day benefit periods, subject to certification as terminally ill with a life expectancy of 6 months or less.

 

How much does medicare pay for hospice per day

 

 

Following the initial coverage period, hospice care under Medicare may be extended through an unlimited series of 60-day benefit periods.

The extension of coverage requires the hospice medical director or another hospice doctor to recertify the patient’s terminal illness through a face-to-face meeting. This means that Medicare covers hospice care for as long as the patient needs it, as long as they continue to meet the eligibility criteria.

Exclusions from Medicare Hospice Coverage

While Medicare hospice coverage is comprehensive, there are some exclusions. Notably, it does not include curative treatments, room and board, or services provided by non-hospice providers. For instance, Medicare does not provide coverage for room and board for hospice patients residing in a facility.

Medicare also does not cover consultations with specialist medical providers for hospice terminal diagnosis. This may require additional financial planning for patients and their families.

Moreover, Medicare does not provide Medicare cover for:

 

  • routine food and nutritional supplements for hospice patients
  • ambulance transportation unless arranged by the hospice
  • emergency department visits or hospitalizations, as typically the hospice does not authorize or arrange them.

Choosing a Hospice Program

Selecting a hospice program is a significant decision that warrants thorough consideration. The role of a hospice doctor involves being part of the medical team that oversees the patient’s care in a hospice program, ensuring their comfort and proper management of the care plan.

 

Does medicaid cover hospice

 

 

Moreover, within a hospice program, a hospice nurse and doctor are available around the clock to offer assistance and care to the patient and their family.

The location of the hospice program is also important, as it determines the preferred place for care delivery and end-of-life arrangements for the patient, which can encompass the patient’s home, hospital, inpatient facility, or nursing home settings.

Finally, the reputation and quality of a hospice program can be assessed through various criteria such as:

 

  • Live discharge rates
  • Average length of stay
  • Hospice care indexes
  • Performance on Hospice Quality Reporting Program (HQRP) measures

 

These factors are related to effectiveness and patient-centered care.

Transitioning In and Out of Hospice Care

The process of transitioning into and out of hospice care is designed with flexibility to adapt to the patient’s changing needs. Indeed, a patient has the ability to:

 

  • Discontinue hospice care at any time
  • Maintain their Medicare coverage upon discontinuation of hospice care
  • Be readmitted to hospice care at any point subsequent to their decision to discontinue it, if they meet the eligibility criteria.

 

 

Medicare coverage

 

 

There is no designated waiting period for re-entering hospice care under Medicare. As long as the patient remains eligible, they can re-enter hospice care under Medicare at any time. This flexibility is essential, as it allows patients to adjust their care based on their changing needs and circumstances.

Summary

In conclusion, Medicare provides comprehensive coverage for hospice care, focusing on comfort and symptom management for individuals with a terminal illness. It covers a range of services, including pain management, medical equipment, and counseling.

The hospice benefit can be extended indefinitely, provided the eligibility criteria are continually met. While there are some exclusions and potential out-of-pocket costs, the coverage is designed to ensure that patients receive the comprehensive, compassionate care they need during a challenging time. Remember, the ultimate goal of hospice care is to provide comfort and support, enhancing the quality of life for patients like Mary in their final days.

Frequently Asked Questions

 

 

Does Medicare cover hospice services yes and here’s exactly what it pays for?

Yes, Medicare covers services, medications, supplies, and equipment related to life-limiting illnesses through the Medicare Hospice Benefit, but it does not cover room and board expenses.

 

Which two conditions must be present for a patient to enroll in hospice?

To enroll in hospice, a patient must have a prognosis of six months or less due to a life-limiting condition and a history of frequent hospitalizations in the past six months. The patient’s declining functional status, determined by factors such as a Palliative Performance Scale (PPS) rating of 50%-60%, is also taken into consideration.

 

What is usually not included in hospice care?

Hospice care usually does not include treatments for curative or life-prolonging conditions, nor does it cover medications used for non-palliative reasons such as cancer treatment, organ transplants, and fertility treatments.

 

Who is eligible for hospice care?

Hospice care is typically for patients with a life expectancy of six months or less, frequent hospitalizations, and progressive weight loss, weakness, and fatigue. It’s important to meet these criteria to be eligible for hospice care.

 

→  What does hospiscare do?

Hospiscare provides specialized care that focuses on physical comfort, emotional, social, and spiritual support for individuals nearing the end of life. This includes a team of doctors, nurses, social workers, and home health aides who prioritize the patient’s comfort and dignity.

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Speak with a licensed insurance agent

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Russell Noga
( Medicare Expert )

Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.